What are the treatment options for interstitial cystitis?

Treatment Options for Interstitial Cystitis/Bladder Pain Syndrome

Treatment for interstitial cystitis/bladder pain syndrome (IC/BPS) should follow a multi-modal approach, starting with conservative therapies and progressing to more invasive options only when symptoms are not adequately controlled, with the goal of maximizing symptom control and quality of life while minimizing adverse events. 1

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential:

• IC/BPS is characterized by bladder/pelvic pain and pressure/discomfort associated with urinary frequency and urgency
• Symptoms should be present for at least six weeks with documented negative urine cultures
• Cystoscopy is indicated when Hunner lesions are suspected, as their presence guides specific treatment 1

Treatment Algorithm

First Line: Behavioral and Non-Pharmacologic Approaches

• Self-care practices and behavioral modifications:
  • Dietary modifications: avoiding bladder irritants (coffee, citrus products)
  • Fluid management: either restriction or additional hydration based on individual response
  • Application of heat or cold over the bladder or perineum for pain relief
  • Stress management techniques: meditation, imagery for flare management
  • Pelvic floor muscle relaxation and bladder training with urge suppression 1

Oral Medications

Several oral medications have shown efficacy:

1. Amitriptyline (Grade B evidence)

   • Start at low doses (10 mg) and titrate gradually to 75-100 mg if tolerated
   • Common side effects: sedation, drowsiness, nausea 1

2. Pentosan polysulfate (Grade B evidence)

   • Only FDA-approved oral medication for IC/BPS
   • Patients should be counseled about potential risk for macular damage and vision-related injuries 1

3. Cimetidine (Grade B evidence)

   • Has shown clinically significant improvement in IC/BPS symptoms, pain, and nocturia 1

4. Hydroxyzine (Grade C evidence)

   • May be particularly effective in patients with systemic allergies
   • Common side effects include short-term sedation and weakness 1

Bladder Instillations

For patients who don't respond adequately to oral therapies:

1. Dimethyl sulfoxide (DMSO)

   • FDA-approved intravesical therapy
   • Dosage: 50 mL instilled directly into bladder via catheter, retained for 15 minutes
   • Treatment repeated every two weeks until maximum symptomatic relief
   • Side effects: garlic-like taste and odor lasting up to 72 hours 2

2. Other intravesical options:

   • Heparin
   • Lidocaine 1

Procedures for Refractory Cases

For patients with inadequate symptom control from previous treatments:

1. Hunner Lesion Treatment

   • If Hunner lesions are present, fulguration (with laser or electrocautery) and/or injection of triamcinolone should be performed 1

2. Neurostimulation

   • Trial of neurostimulation may be performed
   • If successful, permanent neurostimulation devices may be implanted 1

3. Advanced Pharmacologic Options

   • Cyclosporine A (oral)
   • Intradetrusor botulinum toxin A (patients must accept possibility of needing intermittent self-catheterization) 1

Surgical Options (Last Resort)

Reserved for patients with end-stage, small, fibrotic bladders or when all other therapies have failed:

• Substitution cystoplasty
• Urinary diversion with or without cystectomy 1

Pain Management Considerations

• Pain management should be considered throughout treatment
• Multi-modal pain management approaches (pharmacological, stress management, manual therapy) should be initiated
• Non-opioid alternatives should be used preferentially due to the global opioid crisis 1

Important Caveats

• No single treatment has been found effective for the majority of patients
• Acceptable symptom control may require trials of multiple therapeutic options
• Patients should understand that IC/BPS is typically a chronic disorder requiring continual management
• The 2022 AUA guidelines no longer divide treatments into tiered lines, emphasizing that treatment should be based on symptom severity, clinician judgment, and patient preferences 1
• Ineffective treatments should be discontinued and the diagnosis reconsidered if no improvement occurs within a clinically meaningful timeframe

By following this structured approach to IC/BPS treatment, clinicians can help patients achieve optimal symptom control and improved quality of life.